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Forestadent Travel Award

Cleft Palate Unit, Royal Liverpool Children's NHS Trust, Alder Hey Hospital, Eaton Rd, Liverpool L12 2AP, UK.

Introduction

The Forestadent Young Specialist Prize is awarded following the submission of case records of three treated cases displayed in the Clinical Demonstrations section at the annual British Orthodontic Conference. This award is given to support a visit to an overseas orthodontic centre or conference. Cases must have been treated by the orthodontic practitioner within 12 years of initial orthodontic qualification. The three cases presented for the award during the 1998 conference in Torquay are described.

Case Report 1

An 11-year-old Causasian male was referred by his general dental practitioner. He was concerned about the prominence and irregularity of his upper anterior teeth. On examination he presented with a Class II division 1 malocclusion on a Class II Skeletal base. There was mild mandibular retrognathia. The Frankfort-mandibular planes angle and lower anterior face height proportion were average. The lips were incompetent, habitually apart, the upper central incisors resting on the lower lip. There was no history of digit sucking.

Examination of the dentition revealed the permanent teeth, with the exception of 5 | 5, 7| and the third molars, to be erupted. E | E were retained, 6 | 6 were hypoplastic, but the dentition was caries free, and the oral hygiene and gingival condition were good. There was mild crowding of the lower arch with the lower labial segment at a normal inclination. The upper arch was crowded with shortage of space for the erupting 3 | 3. The upper canines were buccally displaced and the upper central incisors were mesiolabially rotated and proclined. The overjet was increased at 9 mm, with an incomplete overbite of 2 mm. The upper centreline was coincident with the facial plane, whilst the lower centreline was 1 mm to the right. The molar relationship was Class II on the right and unit Class II on the left (Fig. 1a–g).

View larger version (559K): [in this window] [in a new window]   FIG. 1 (a–g) Case report 1: pretreatment records.

1. provision of space for upper arch alignment;
   
2. retraction of the upper labial segment, while maintaining the existing lower incisor position, to camouflage the underlying skeletal discrepancy;
   
3. obtain Class I molar and incisor relationships;
   
4. co-ordination of both arches, improving the crossbite tendencies.
   

The treatment plan was as follows:

1. transpalatal arch to bands 7 | 7 for anchorage reinforcement;
   
2. extraction 6E | E6;
   
3. upper and lower fixed appliances for alignment, levelling, and retraction of the upper labial segment;
   
4. headgear to be used for anchorage reinforcement if required.
   

Treatment was completed with 17 visits over a 19-month period. The transpalatal arch alone was worn during the first 3 months until the extractions were completed and the 5 | 5 had erupted. An upper pre-adjusted Edgewise fixed appliance (0•022 x 0•028-inch Roth prescription bands and brackets) was then placed. Upper canine retraction was achieved by means of lace-backs and the upper incisor attachments gradually engaged. Seven months into treatment a lower pre-adjusted Edgewise fixed appliance (Roth prescription bands and brackets, lower incisor brackets with 6-degree lingual crown torque) was provided. Anchorage was reassessed throughout treatment but headgear was not needed. Co-ordinated 0•019 x 0•025-inch stainless steel working archwires were used in the last 4 months of treatment. The upper archwire had additional buccal root torque 2 | 2. Class III elastics were also used in the last three months before debond. Following debond, retention in the form of an upper Hawley retainer and lower fixed lingual arch was provided.

Case 1 Assessment
During treatment the overjet reduction and improvement in interincisal angle occurred principally as a result of upper incisor retraction to camouflage the skeletal discrepancy. The lower incisors were minimally proclined. Additionally, the cephalometric superimpositions revealed that there was considerable downward and forward growth of both the maxilla and mandible. Maxillary growth was a little less than that of the mandible and this resulted in a small reduction in ANB angle (Fig. 3).

View larger version (22K): [in this window] [in a new window]   FIG. 3 Case report 1: cephalometric superimposition.

Case Report 2

This 12-year-old girl, at boarding school locally, was referred by her General Dental Practitioner. She was unhappy about the appearance of her top front teeth. On examination she presented with a Class II division 2 malocclusion on a Class II Skeletal base. There was mild mandibular retrognathia. The Frankfort-mandibular planes angle and lower anterior face height proportion were average. The lips were competent. There was no history of digit sucking or other habits.

Examination of the dentition revealed the permanent teeth, with the exception of the third molars and upper second molars to be erupted. The teeth were caries and restoration free, and the oral hygiene and gingival condition were good. There was mild generalized fluorosis. The lower arch was well aligned with mild spacing in the lower premolar regions. The lower labial segment was at a normal inclination. The anterior segment of the upper arch was crowded with 2 | 2 proclined. The upper central incisors were retroclined. The overjet was increased to 7 mm, measured to | 2. The overbite was increased to 7 mm and was complete to the palatal mucosa at the gingival margin 21 | 12. Both upper and lower centrelines were coincident with the midfacial plane. The molar relationship was unit Class II on the right and Class II on the left (Fig. 4a–g).

View larger version (551K): [in this window] [in a new window]   FIG. 4 (a–g) Case report 2: pretreatment records.

1. provision of space for upper arch alignment;
   
2. levelling of both arches for overbite reduction, minimizing lower incisor proclination as far as possible;
   
3. torquing of upper central incisors to improve interincisal angle;
   
4. obtain Class I molar and incisor relationships.
   

The treatment plan was as follows:

1. headgear to 6 | 6 for distal movement;
   
2. upper removable appliance with flat anterior bite-plane to reduce the overbite and springs to encourage distal movement of 6 | 6;
   
3. lower fixed appliance to level lower arch;
   
4. upper fixed appliance for upper arch alignment, and torquing of 1 | 1.
   

Treatment was completed with 15 visits over a 19-month period. It was started with combination safety headgear to Roth prescription bands 6 | 6, together with the upper removable appliance. After 4 months the molar relations were nearing Class I and a lower pre-adjusted Edgewise fixed appliance (Roth prescription bands and brackets, lower incisor brackets with 6-degree lingual crown torque) was provided. Two months later, a lower 0•018-inch stainless steel archwire was placed, and the upper removable appliance was discontinued to permit spontaneous movement of upper premolars and canines into the available space. At the subsequent appointment Roth prescription brackets were placed on the upper premolars and canines, with supertorque (17-degree palatal root torque in 1 | 1) brackets to the upper incisors. Once upper and lower 0•019 x 0•025-inch stainless steel working arches had been placed, upper arch space was closed by means of elastic chain in the 3 months prior to debond. Combination headgear continued throughout treatment. A unilateral Class II intermaxillary elastic was worn for two months towards completion. Following fixed appliance removal an upper removable Hawley retainer was provided. Retention was not used in the lower arch (Fig. 5a–g).

View larger version (604K): [in this window] [in a new window]   FIG. 5 (a–g) Case report 2: post-treatment records.

View larger version (21K): [in this window] [in a new window]   FIG. 6 Case report 1: cephalometric superimposition.

This 12-year-old boy was referred by his General Dental Practitioner. He was concerned that his top teeth stuck out. On examination he presented with a Class II division 1 malocclusion on a Class II Skeletal base. The Frankfort-mandibular planes angle and lower anterior face height proportion were average. The lips were incompetent, apart at rest, with the upper central incisors lying on the lower lip. There was no history of digit sucking or other habits.

Examination of the dentition revealed the permanent teeth, with the exception of the third molars to be erupted. The oral hygiene and gingival condition were good. Caries was controlled with small occlusal amalgam restorations in all four first permanent molars. The lower arch was well aligned with a small space in the lower left premolar region. The lower labial segment was at a normal inclination. The anterior segment of the upper arch was spaced and a little proclined. The overjet was increased to 8 mm. The overbite was increased to 5 mm and was complete to the palatal mucosa at the gingival margin 1 | 1. The upper centreline was coincident with the midfacial plane. The lower centreline was 3 mm to the left. The molar relationship was Class I on the right and Class II on the left. There was a scissors bite involving the premolars on the right side. There was a mandibular displacement on closure, with initial contact on the right premolars, followed by displacement of 1 mm to the left on closure into the intercuspal position (Fig. 7a–g).

View larger version (571K): [in this window] [in a new window]   FIG. 7 (a–g) Case report 3: pretreatment records.

1. Restrain the maxillary dentition and forward maxillary growth, while maintaining the lower incisor inclination. Together with mandibular growth, aim to create Class I incisor and molar relations.
   
2. Alignment and levelling with co-ordination of both arches, correcting the scissors bite and mandibular displacement on closure.
   
3. Space closure.
   

The treatment plan was as follows:

1. Headgear to upper removable appliance with cribs to upper first molars and upper first premolars, and a flat anterior bite plane.
   
2. Review regarding extraction of 7 | 7 depending on progress.
   
3. Lower fixed appliance for alignment, levelling, and arch co-ordination.
   
4. Upper fixed appliance with continued headgear support to retract the upper labial segment, align, and co-ordinate the upper arch and close space.
   

Treatment was completed with 22 visits over a 27-month period. It was started with safety high-pull headgear to an upper removable en-masse appliance (cribs 4 | 4, cribs with tubes for extra-oral traction 6 | 6, and a flat anterior bite plane. After 3 months the molar relations were improving and a lower pre-adjusted Edgewise fixed appliance (Roth prescription bands and brackets) was provided. The lower archwires were gently expanded in the lower premolar regions to reduce the scissors bite. A second upper removable appliance with an increased bite plane and a T-spring to expand 6 | was provided 10 months into treatment. By 13 months into treatment, the right molar relation was Class III, the left Class I. An upper pre-adjusted Edgewise fixed appliance (Roth prescription bands and brackets) was then provided. Thereafter, headgear was continued as required to maintain the molar anchorage. Once in an upper 0•019 x 0•025-inch stainless steel working arch space was closed and the upper labial segment retracted using nickel titanium closing springs the upper incisors. Correction of the molar relation on the right and of the centreline relationships was by means of a right unilateral Class III intermaxillary elastic together with an anterior cross-elastic from upper right canine to lower left canine, which were worn for 5 months towards completion. Following fixed appliance removal an upper removable Begg-type retainer was provided together with a fixed lower lingual arch to bands on the lower second premolars (Fig. 8a–g).

View larger version (593K): [in this window] [in a new window]   FIG. 8 (a–g) Case report 3: post-treatment records.

The scissors bite of the right premolars was corrected principally by contraction of the upper arch, but also by a little lower premolar expansion. The centreline discrepancy and asymmetric molar relationships were corrected partly by elimination of the scissors bite and mandibular displacement, and partly by unilateral Class III elastic and anterior cross-elastic wear.

At the completion of treatment the upper incisors had been brought within lower lip control and consequently it was anticipated that the improved incisor relation would remain relatively stable following retention (Fig. 9).

View larger version (23K): [in this window] [in a new window]   FIG. 9 Case report 3: cephalometric superimposition.

View larger version (645K): [in this window] [in a new window]   FIG. 2 (a–g) Case report 1: post-treatment records.

I would like to thank the staff of the Orthodontic Department of the Countess of Chester Hospital for assistance during the treatment and presentation of these patients. I would also like to thank Mr N. M. Brown of Forestadent for sponsoring this award.

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